Periodontists
The focal point of the link between oral health and systemic health
Editor’s Note: Knowing your customer is an important part of the sales process. This month, First Impressions takes a look at the issues and challenges facing periodontists.
The coming years may be a time for "getting back to basics" for periodontists. And the "basics" - preventing, diagnosing and treating gum diseases - are more important than ever.
That’s because of growing evidence linking periodontal disease with other systemic diseases, including cardiovascular disease, kidney disease and diabetes. Though the connection between periodontal and systemic health has been known to dentists and medical doctors for some time, the word may be filtering out to the public at large. If so, periodontal services may be more in demand than ever in the coming years.
To a certain extent, periodontics has - as other dental specialties - been a victim of a "blurring of the specialties," says Susan Karabin, DDS, a practicing periodontist in New York City, assistant clinical professor at Columbia University College of Dental Medicine, and past president of the American Academy of Periodontology. Procedures that used to be the domain of, say, surgical specialists, are now being performed by generalists. Similarly, some of the things that periodontists used to do exclusively, such as soft tissue grafting, are now being done by oral surgeons. And endodontists are now doing implants and oral procedures. "There’s an identity crisis among the specialties," she says. What’s needed is for each one to find its niche.
"The periodontal/systemic link has made what we do more important," says Karabin. "Finding ways to make the mouth healthy and the body healthy will be the way we will keep our specialty alive and well."
The American Academy of Periodontology (AAP) reports that it has about 3,700 active members, a number that has stayed fairly consistent over the past 10 years. About 2 percent of dental students opt to specialize in periodontics, again, a number that has stayed consistent for the past decade.
Consensus paper
The most recent link between periodontal disease and cardiovascular disease was a recently published consensus paper on the subject by the American Journal of Cardiology, a publication circulated to 30,000 cardiologists; and the Journal of Peridontology, the official publication of the AAP.
Cardiovascular disease, the leading killer of men and women in the United States, contributes to 2,400 deaths each day. Periodontal disease, a chronic inflammatory disease that destroys bone and gum tissues that support the teeth, affects nearly 75 percent of Americans and is the major cause of adult tooth loss. The common link between them is inflammation.
While inflammation initially intends to have a protective effect, untreated chronic inflammation can lead to dysfunction of the affected tissues, and therefore to more severe health complications, according to the AAP.
"Both periodontal disease and cardiovascular disease are inflammatory diseases, and inflammation is the common mechanism that connects them," said Dr. David Cochran, DDS, Ph.D., president of the AAP and chair of the Department of Periodontics at the University of Texas Health Science Center at San Antonio, when the consensus paper was published. "The clinical recommendations included in the consensus paper will help periodontists and cardiologists control the inflammatory burden in the body as a result of gum disease or heart disease, thereby helping to reduce further disease progression, and ultimately to improve our patients’ overall health."
"Since several studies have shown that patients with periodontal disease have an increased risk for cardiovascular disease, we felt it was important to develop clinical recommendations for our respective specialties," said Kenneth Kornman, DDS, Ph.D., editor of the Journal of Periodontology and a co-author of the consensus report, at the time of the publication. "Therefore, you will now see cardiologists and periodontists joining forces to help our patients."
Developed by cardiologists and periodontists, the paper contains clinical recommendations for both medical and dental professionals to use in managing patients living with, or who are at risk for, cardiovascular or periodontal disease. As a result of the paper, cardiologists may now examine a patient’s mouth, and periodontists may begin asking questions about heart health and family history of heart disease.
"Periodontal disease used to be thought of as an infectious disease, whereas now it’s considered an inflammatory disease," adds Karabin. "[It] contributes to the inflammatory burden of the body. So it makes control of this disease much more important than we thought in the past."
In years past, the loss of a tooth or two was regarded as unfortunate, but not potentially life-threatening. But considering the link between gum disease and other diseases, tooth loss becomes much more significant, says Karabin. "So instead of tolerating a low level of inflammation in the mouth, now [we know] we need to control it better. How that changes the way we treat it clinically is probably something that will evolve over the next few years." More antimicrobials, and more local delivery, are two ways periodontists might attempt to keep inflammation under tighter control.
Cardiovascular disease isn’t the only condition linked to periodontal disease. A 2008 study, conducted at Case Western Reserve University and reported on in the Journal of Periodontology, suggested that edentulous, or toothless, adults may be more likely to have chronic kidney disease than others. The study examined the kidney function and periodontal health indicators, including dentate status, of 4,053 U.S. adults 40 years of age and older, according to the AAP. After adjusting for recognized risk factors of chronic kidney disease such as age, race/ethnicity and smoking status, the results revealed that participants who lost all their teeth were more likely to have chronic kidney disease than patients who had maintained their natural dentition.
Economics favor periodontics
There’s no doubt that periodontists, as other dental specialists, are facing lean times, reflecting the state of the economy at large. "Everyone’s having a hard time," says Karabin. "We depend on referrals from general dentists, and they’re having a hard time. But I think there’s a segment of the population who understand that in this economy, you need to stay healthy. They recognize that doing the normal maintenance and preventive procedures are still a good bang for your buck."
Involvement by insurers could stimulate the profession. Indeed, a 2007 study in Japan of 4,285 patients over three and a half years found that cumulative healthcare costs were 21 percent higher for patients with severe periodontal disease (involving bone loss and diminished attachment around the teeth) than those with no periodontal disease.
"I think insurers will be very interested in this information [linking oral and systemic health]," says Karabin. In fact, after lecturing recently to a group of payers, she found widespread interest in providing preventive dental care to pregnant women and others. "I think they’re looking at risks, and they see periodontal disease as one of the risk factors for systemic disease," she says. By paying for preventive dental care, insurers may help their patients avoid complicated - and expensive - medical issues down the line.
Sales rep’s role
From a technological point of view, Karabin says she is excited by research into and development of growth factors, which can stimulate bone production faster than was previously possible. "I can regenerate tissues that were lost, something I couldn’t do 10 years ago."
And she says distributor sales reps can be a potentially key part of the future of her profession, "not only by providing good service and good products at reasonable prices - that’s the baseline," she says. Rather, reps can be a link between general dentists and specialists, and among specialists themselves. They are bearers of news of what other professionals are doing successfully. Furthermore, they are born networkers. Having heard of an opening in one practice, they may have become aware of someone who recently lost their job in another. Calling on so many customers, "they are in a unique position to assess practices and connect people," says Karabin.
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